Executive Summary

An estimated 1.7 million health care-associated infections occur each year in the United
States resulting in over 98,000 deaths.1 A recent study conducted by the Centers for Disease
Control and Prevention estimated that there were 94,000 invasive MRSA infections in the United
States in 2005, 86% of which were health care-associated.2 Furthermore, the proportion of all S. aureus isolates that are resistant to methicillin has been increasing each year and MRSA now
accounts for over 60% of all S. aureus isolated from intensive care unit patients.3

This report serves as the Minnesota Department of Health (MDH) Recommendations for
Methicillin-Resistant Staphylococcus aureus (MRSA) Control in Acute Care Facilities (hereafter
referred to as The Recommendations) as required under Minnesota Statutes, section 144.585.
The purpose of this document is to provide a standard set of recommendations for the prevention
and control of MRSA in acute care facilities in Minnesota. It is expected that facilities will
implement The Recommendations by January 1, 2009.

This document was created to enhance rather than duplicate existing published
recommendations and guidelines for MRSA control in acute care settings. Extensive literature
reviews, expertise from the MDH MRSA Recommendations Task Force (MDH-MRTF) and
discussions with national content experts served as the basis for the Recommendations. MDH
will review The Recommendations annually and modify them as needed to reflect new scientific
developments concerning effective MRSA prevention and control.

Public comments were solicited on a draft version of The Recommendations. The MDH
MRSA Recommendations Task Force (MDH-MRTF) reviewed and evaluated the public
comments and made revisions to the draft version in creating the final Recommendations.

Minnesota Statutes, section 144.585 states: “In developing the MRSA recommendations,
the Department of Health shall consider the following infection prevention and control practices:
1) identification of MRSA-colonized patients in all intensive care units (ICU) or other at-risk
patients identified by the hospital; 2) isolation of identified MRSA-colonized or MRSA-infected
patients in an appropriate manner; 3) adherence to hand hygiene requirements; and 4) monitor
trends in the incidence of MRSA in the hospital over time and modify interventions if MRSA
infection rates do not decrease.”

Infection prevention and control practices two through four in the statute are included in
The Recommendations as standard MRSA infection prevention and control practices for acute
care facilities. The statute also calls on MDH to consider active surveillance testing in a subset of
patients (practice 1 in the statute). The MDH-MRTF carefully considered this practice and
concluded that requiring identification of MRSA-colonized patients through active surveillance
testing in a pre-defined subset of patients for all admissions, at all times, in all acute care
facilities in Minnesota is not the ideal approach to decrease health care-associated MRSA and
other health care-associated infections. The main factor behind this decision is that acute care
facilities, the populations they serve (including populations with varying degrees of risk for
MRSA) and the services they provide, vary across the state. Rather than requiring active
surveillance testing in a pre-defined subset of patients, The Recommendations require acute care
facilities to conduct an annual MRSA risk assessment using active surveillance testing to identify
patients at high risk for MRSA colonization or units with high rates of MRSA transmission.
This process will allow acute care facilities to identify, target and monitor interventions to their
individually identified high-risk populations and/or units creating the potential for greater
reduction in transmission of MRSA. Under The Recommendations, acute care facilities must
also consider the standard use of active surveillance testing in targeted populations or units as a
part of an enhanced infection prevention and control program when routine infection prevention
and control practices do not result in decreased MRSA infection rates.

The Recommendations are comprised of four sections: Infrastructure and culture to
support MRSA infection prevention and control, Baseline infection prevention and control
recommendations, Tier One Recommendations, and Tier Two Recommendations. The baseline
infection prevention and control recommendations will prevent the transmission of MRSA and
be useful in decreasing transmission of other health care-associated infections including
Clostridium difficile, extended-spectrum beta-lactamase producing Gram-negative bacteria, and
vancomycin-resistant enterococci. Transmission of MRSA within acute health care facilities is of
great concern, although it is estimated that MRSA is responsible for less than 15% of all
health care-associated infections.4,5

General infection prevention and control measures include administrative support,
process measures, and infection prevention and control measures. Administrative support for
infection prevention and control activities (e.g. adequate funding and staffing) is critical to the
success of programs aimed at reducing health care-associated infections. Process measures
involve implementing a group of interventions that, when used together, have been shown to
achieve better health care-associated infection prevention outcomes than if implemented alone
such as interventions for preventing ventilator-associated pneumonia, central-line associated
bloodstream infections, and surgical site infections.6,7 Infection prevention and control measures
include hand hygiene, Standard Precautions and Transmission-Based Precautions.

In addition to general infection prevention and control measures, The Recommendations
adopt a two-tiered approach for preventing and controlling MRSA transmission in acute care
facilities. Tier One Recommendations for MRSA control in acute care settings include core
MRSA infection prevention tools such as strict adherence to Contact Precautions, adherence to
recommended hand hygiene practices, and thorough environmental cleaning. In facilities not
performing facility-wide active surveillance testing, Tier One Recommendations require acute
care facilities to conduct an annual MRSA risk assessment using active surveillance testing to
determine populations or units at risk for MRSA colonization and/or to determine MRSA
transmission rates. This annual assessment will assist facilities in determining when Tier Two
Recommendations are indicated.

Tier Two Recommendations are indicated when hospital-acquired MRSA infection rates
are not decreasing despite implementation of and adherence to the general infection prevention
and control measures and Tier One Recommendations. Tier Two Recommendations call for
monitoring health care worker compliance with infection prevention and control measures in
identified high-risk units or populations, intensified environmental measures, and active
surveillance testing for all admissions to identified high-risk units or of high-risk populations.

Prevention and control of MRSA necessitates that health care facilities implement an
antimicrobial stewardship program to augment their infection prevention and control program.
Antibiotic misuse, including overuse of broad-spectrum antibiotics, is the biggest driver of
antimicrobial resistance and contributes appreciably to the development of resistant organisms
including MRSA. Effective antimicrobial stewardship programs are necessary to optimize
therapeutic outcomes while minimizing unintended consequences of antimicrobial use.8

Facility-wide commitment to antimicrobial stewardship and infection prevention and
control practice measures are essential to prevent health care-associated infections. An
institutional philosophy that supports these elements is critical to achieving success in decreasing
transmission of MRSA and other health care-associated infections.